| NPI | 1023329778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: VA 0401416242) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.023261) |
| Enumeration Date | 2010-06-28 |
| Last Update Date | 2018-12-05 |